Brian Whitfield sat on the floor of his office, back against the wall, gun in hand and a heavy-duty garbage bag nearby. The gun was intended to kill himself. The garbage bag was meant to help whoever had the misfortune of finding him clean up the aftermath. His wife, he assumed. He had contemplated suicide multiple times in the months leading up to this moment, even drawing up a last will and testament. But the day with the gun was the only time he signed and sealed the detailed letter to his wife. It was the first time he actually held the gun in his hand, and it was the first time he considered a garbage bag. He loved a clean house and hated the idea of creating such a mess.

Whitfield says he still can’t pinpoint why he felt so intensely depressed or abandoned in those moments.

The chaos began about five years before, in 2011, when Whitfield visited multiple doctors for pain from knee and back injuries he had sustained while serving in the Marine Corps several years earlier. Despite surgery, the pain had worsened over time. Both Veterans Affairs and private doctors he saw agreed that long-term pain management with opioids was the only way of giving him relief.

The overprescription and pervasive abuse of opioids has become well-worn news, as the nation grapples with millions addicted to both legal and illicit opioid drugs (mostly heroin), which have been the leading cause of accidental death in the U.S. for several years. In 2017, the drugs killed more than 70,000 people — more than any year on record, according to numbers from the Centers for Disease Control and Prevention that were released in December. Overdose deaths in the most recently recorded data were so high that they contributed to a decrease in overall life expectancy in the U.S. for the third year in a row, depressing the average to 78.6 years.

Despite being aware of the addictive properties of the drugs, Whitfield says he felt little hesitation about taking the medication. He read the required pamphlets of information about side effects and risks, and signed the form acknowledging and accepting them. Becoming dependent on the drugs, he says, was something that “would never happen to me.” After signing the forms, Whitfield says the risks of addiction were never mentioned again by doctors.

The opioid epidemic is a uniquely American problem. While the U.S. accounts for about 5 percent of the global population, its residents consume about 80 percent of the global supply of prescription opioids. The question becomes: Why are Americans in so much pain?

It’s not that Americans experience severe injuries or suffer from chronic pain at notably higher rates than, say, Europeans, according to experts. In fact, a 2018 report published by BMC Public Health found that Europeans report similar rates. In France, Italy and Ukraine, individuals report even higher rates of chronic pain (around 40 percent) than in the United States, where about 20 percent of the adult population (or 50 million people) report some sort of chronic pain.

The explanation for America’s prodigious opioid consumption is complicated, involving both personal expectations and societal norms, medical practices and the influence of powerful pharmaceutical companies whose marketing tactics take advantage of a fast-paced lifestyle and a “get-it-fixed” culture, all while the medical community in, say, Europe tends to be more open to alternative and natural therapies than that in the United States.

Big Pharma has spent billions on marketing to physicians, including offers of free vacations, dinners, speaking fees and other perks. Just last week, a new study published in JAMA Network Open examined more than 400,000 marketing payments in the U.S. for a potential link between physician-focused marketing and opioid-related deaths. The results showed that counties where marketing to doctors was heaviest had the greatest incidence of over-prescribing of opioids, as well as subsequent abuse and related deaths.

Still, despite the dangers of opioid addiction having been splashed across the headlines for years now, many Americans trust the drugs to offer pain relief for themselves and their loved ones more than any other therapy. A new study from the American Society of Anesthesiologists, published Monday, surveyed more than 1,000 parents with children between the ages of 13 and 24 and found that two-thirds believe opioids are more effective at managing their child’s pain after surgery or a broken bone than nonprescription medication or other alternatives.

Ana Jovanovic, a writer with Parenting Pod and a psychologist who works with clients from the U.S. and Europe, says that though her European clients also want fast, affordable health solutions, they “don’t trust the pharmaceutical companies” as much as Americans do. “My U.S.-based clients tend to feel that drugs are a reliable solution to start with,” Jovanovic says. “My European clients usually only take medication after they have already started with counseling, physical therapy or coaching, and only if it’s really necessary.”

Direct-to-consumer advertising by major pharmaceutical companies has also had a significant effect on pain management expectations in clients, says Chris Lee, a health care consultant and marketing manager at Family Health Centers of San Diego. “Unlike most countries, the United States allows direct-to-consumer drug ads. ‘Ask your doctor about [drug name],’ they advise patients. This generates demand levels that are simply not seen in other countries.”

The United States and New Zealand are the only two countries in the world to permit direct-to-consumer pharmaceutical advertising, which is defined by the NIH as an effort (usually via popular media) to promote a drugmaker’s prescription products directly to the public.

A pill may seem less daunting than alternative therapies and this, generally speaking, is attractive to U.S. consumers, Lee says. “American culture values comfort and convenience. We see this in our daily consumption habits. We want things, and we want them fast. So it’s no surprise that when we’re in even modest pain and ‘there’s a pill for that,’ we want the pain to go away. We have low tolerance for discomfort. Just as we eat when we’re not quite hungry, we take pain medication even though the pain is tolerable.”

Looking back, Whitfield knew something wasn’t right while he was taking pharmaceutical painkillers, but he never sought help as he began to spiral into addiction, depression and anxiety. He had always considered himself a strong-willed, strong-minded person. “As weak as I was, I felt that it would be weaker to seek the help I needed. … But I was no match for the chemical changes these pills cause. … I was ignorant and foolish to think so.”

So Whitfield mostly suffered in silence, hiding his addiction as much as possible, which Jovanovic says can also be a typically American trait. Compared with Europeans, “people [in the U.S.] tend to invest a lot of energy in portraying themselves as confident, happy and successful. … Sharing inner struggles tends to impose a threat to the idealistic picture they created for themselves and others. So, they choose not to share, which leaves them alone in dealing with the struggles.”

Several months into Whitfield’s treatment plan and taking the recommended daily dosage for his knee and back injuries, his tolerance to the drug increased. He began upping the doses to two or three times the prescribed amount “just to feel normal.” This is a common occurrence in long-term opiate users, experts say, because, among many reasons, the drugs will eventually heighten one’s sensitivity and perception to pain. In time, he was taking five or six pills at once with alcohol just to fight off withdrawals and “bad feelings.”

A previous milestone in opioid prescription was marked in the late 1990s, when the Joint Commission — a U.S.-based organization that accredits more than 21,000 health care organizations and programs — established pain as the “fifth vital sign.” Along with checking blood pressure, body temperature, and pulse and respiration rate, nurses and doctors began asking patients to rate their pain from 1 to 10, or to point to an emoji-style chart that featured faces ranging from smiling to frowning to indicate severity. Doctors say the results were inherently subjective and never offered a clear objective measure for pain.

Unsurprisingly, the number of opioid prescriptions steadily increased after this measurement was introduced, with over 250 million prescriptions for the pain medication written in 2012, according to Dr. Sarah Johnson, medical director at Landmark Recovery.

“Mandates that physicians aggressively treat pain by health care systems potentially contributed to lower tolerance of pain by Americans, and increased expectations that pain be eliminated, rather than viewed as a chronic health condition to be lived with,” says Johnson.

The American Medical Association scrapped the recommended “fifth vital sign” pain measurement in 2016. Since then, scientists have been working toward a better way to gauge patients’ pain. Around the country, NIH researchers are currently studying pupil reactions, brains scans and other definitive markers of pain to better assess individual patients.

“Perception of pain varies between patients and should be addressed on an individualized basis,” Johnson says. “As a culture, we could better work through pain by being more open minded to nonmedication therapies for pain, such as physical therapy to treat underlying conditions in chronic pain, and relaxation, — as well as sometimes learning to live with some degree of pain and enjoy life if it cannot be completely cured.”

As income inequality continues to grow in the U.S., experts have begun to look at how socioeconomic factors might contribute to pain and drug abuse, as well. Authors of a CDC report published in September found that “socioeconomic status appears to be a common factor in many of the subgroup differences in high-impact chronic pain prevalence. Education, poverty, and health insurance coverage have been determined to be associated with both general health status and the presence of specific health conditions as well as with patients’ success in navigating the health care system.”

The report found unemployed older adults, adults living in poverty, rural residents and people without public health insurance are significantly more likely to experience chronic pain, while the risk of pain is lower for people who have earned a bachelor’s degree.

That could be because the emotional stress of financial insecurity can have a direct effect on one’s physical pain level, according to data published in Psychological Science in 2017. In data from a diverse group of more than 33,000 patients, they found that households with two unemployed adults spent 20 percent more on over-the-counter pain medication than households with at least one employed person.

This could explain why some of the poorest U.S. states, and those with higher unemployment rates, including Kentucky and West Virginia, have some of the highest rates of opioid use and addiction. In addition, nearly 75 percent of men and over 60 percent of women are obese or overweight in the U.S., and related health problems, including chronic pain, can be common co-morbidity conditions.

Johnson says Americans and the medical community should work toward changing the conversation about pain: “In our society, pain has a negative connotation and can cause people to think that they cannot do things or cannot enjoy life. By accepting pain as a normal and common physical occurrence, we can have more realistic expectations for pain control.”

Whitfield didn’t go through with the suicide the day with the gun, but he didn’t stop using opioids, either. It wasn’t until months later when he last touched the prescription pills, on April 1, 2016, when he woke up from a blackout, which he believes was an accidental overdosed, after swallowing eight prescription pills with a shot of whiskey hours before. After that, he quit cold turkey, which he says was a “different type of hell” and one he’d “never recommend.” He now manages his pain with a regimen of targeted exercises and natural remedies, though it will never go away completely. And he has also launched a nonprofit, the Life After Project, which is aims to spread awareness about suicide, and substance and domestic abuse by fighting stigma and creating connection.

“I cannot stress it enough how important it is to find a support group, online or in person, or to seek professional help,” says Whitfield. “Knowing you are not alone — and no one is — there are people everywhere willing and able to be there for you. That is a vital part of getting through a hard time.”